Burgess Square Healthcare Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for and report changes in existing pressure ulcers, prevent the development of new pressure areas, and failed to ensure pressure ulcer treatments were in place. This failure resulted in delayed identification of a resident's stage two coccyx pressure ulcer deteriorating to a necrotic and unstageable pressure ulcer, with a subsequent delay in treatment changes. This applies to 2 out of 4 (R1and R4) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared under sanitary conditions and the kitchen was maintained in a clean and sanitary condition. The facility failed to ensure dietary staff utilized hair restrains while preparing food. This failure applies to all 136 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices regarding hand hygiene and gloving during provisions of perineum and wound care. The facility also failed to ensure the use of complete PPE (Personal Protective Equipment) for caring of residents who are on EBP (Enhance Barrier Precaution). This applies to 4 of 27 residents (R13, R20, R105, R152) reviewed for infection control in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to offer residents the updated 2025-2026 COVID-19 vaccine. This applies to 5 of 5 residents (R13, R39, R78, R97, and R112) reviewed for immunizations in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity by maintaining adequate draping and privacy during personal care and assisting a resident in a dignified manner during feeding. This applies to three residents (R31, R107, and R152) reviewed for dignity in a sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer residents. This applies to 2 of 2 residents (R5 and R105) reviewed for transfers in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed provide catheter and peri-care in a manner that would prevent urinary tract infection (UTI). This applies to 2 of 4 residents (R20, R152) reviewed for perineum and catheter care in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered and following standards of care and facility policy. There were 25 medications and 3 errors resulting in a 12% medication error rate. This applies to 1 of 4 residents (R65) reviewed for medication administration in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were offered the pneumococcal vaccine. This applies to 2 of 5 residents (R13 and R78) reviewed for immunizations in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to administer blood thinner medication as ordered by the physician. This failure resulted in R1 experiencing an elevated INR (International Normalized Ratio) blood test and requiring the administration of Vitamin K and hospitalization. This applies to 2 of 3 residents (R1, R4) reviewed for medication administration in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of resident proptery as per the facility abuse policy. This applies to 5 of 6 residents (R1-R4, and R6) reviewed for misappropriation of proptery in a sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely reposition a resident and failed to secure oxygen tanks to prevent them from falling and combusting. This applies to 9 of 9 residents (R14, R2, R32, R371, R379, R26, R41, R45, and R84) reviewed for accidents and supervision in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store medications. This applies to 5 of 5 residents (R373, R171, R425, R272, and R274) reviewed for medication storage in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for residents on transmission-based precautions. This applies to 5 of 5 residents (R325, R324, R62, R45, R374) reviewed for infection control in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure intravenous medications were administered by qualified staff. This applies to 3 of 4 residents (R321, R324 and R426) reviewed for intravenous therapy in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper catheter care, secure catheter tubing placement, and safely anchor the catheter drainage bag. This applies to 2 of 3 (R374 and R45) reviewed for urinary catheters in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify Percutaneous Endoscopic Gastrostomy tube (PEG tube) placement prior to administering medications through PEG-tube and failed to properly administer water flushes and medications via the G-tube. This applies to 1 of 1 resident (R171) reviewed for medication administration via PEG-tube in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change residents' PICC (Peripherally Inserted Central Catheter) dressings, measure arm circumferences, and external catheters as ordered for intravenous catheters. This applies to 2 of 4 residents (R374 and R424) reviewed for intravenous catheters in a sample of 31.

Inspectors wroteBased in observation, interview, and record review, the facility failed to get an order for oxygen for a resident receiving oxygen. This applies to 1 of 1 resident (R322) reviewed for oxygen administration in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify the counting logs accuracy for residents with controlled medications, and failed to dispose of controlled medications per facility policy. This applies to 2 out of 2 (R377 and R378) residents reviewed for control medications in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent the development of pressure sores. This failure resulted in R1 developing a Stage 3 pressure sore to her sacrum. This applies to three of four residents (R1, R3 and R4) reviewed for wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care and prevent Moisture Associated Skin Damage. This applies to two of four residents (R1 and R2) reviewed for incontinence care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow menu portion serving sizes for mechanical soft and pureed diets. This applies to 5 of 5 residents (R20, R29, R32, R60, R111) observed for dining in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thickened soup to a resident with swallowing problems, and failed to serve ground barbeque pork for mechanical soft diets. This applies to 5 of 5 residents (R6, R33, R46, R69, and R315) reviewed for dining in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provision of care, and failed to follow enhanced barrier precautions. This applies to 11 of 24 residents (R20, R84, R51, R67, R80, R96, R167, R265, R267, R316 and R317) reviewed for infection control in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for a resident to receive and self-administer a home medication. This applies to 1 of 24 residents (R106) reviewed for self-administration of medication in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician order for a Do Not esuscitate. This applies to 1 of 4 residents (R109) reviewed for advanced directives in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to remove a staff member from duty after a resident voiced an allegation of verbal abuse. This applies to1 resident (R92) reviewed for abuse in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change the resident's midline dressing to ensure integrity of the catheter and to prevent potential IV (intravenous) site infection per physician's order, plan of care, and per facility's infusion manual. This applies to 1 of 2 residents (R167) reviewed for IV lines in the sample of 24.